Provider Demographics
NPI:1699799346
Name:SDAO, ROGER (DC)
Entity type:Individual
Prefix:DR
First Name:ROGER
Middle Name:
Last Name:SDAO
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:455 W. STEPHENSON ST.
Mailing Address - Street 2:
Mailing Address - City:FREEPORT
Mailing Address - State:IL
Mailing Address - Zip Code:61032
Mailing Address - Country:US
Mailing Address - Phone:815-297-1807
Mailing Address - Fax:
Practice Address - Street 1:455 W. STEPHENSON ST.
Practice Address - Street 2:
Practice Address - City:FREEPORT
Practice Address - State:IL
Practice Address - Zip Code:61032
Practice Address - Country:US
Practice Address - Phone:815-232-4217
Practice Address - Fax:815-233-3379
Is Sole Proprietor?:No
Enumeration Date:2006-07-26
Last Update Date:2016-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038-009058111NX0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NX0800XChiropractic ProvidersChiropractorOrthopedic
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL350049409OtherMEDICARE RAILROAD
ILK13270OtherMEDICARE MEMBER #
IL08925958OtherBLUE CROSS BLUE SHIELD #
ILK13270OtherMEDICARE MEMBER #
IL08925958OtherBLUE CROSS BLUE SHIELD #